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More has been learned about sleep in the last 60 years than in the past 6000 years Mansoor Ahmed. MD, FACCP, FABSM Medical Director, Cleveland Sleep & Research Center Assistant Professor of Medicine Case Western Reserve University Fellow American Academy of Sleep Medicine .

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overview of sleep disorders sleep medicine 60 years of progress

More has been learned about sleep in the last

60 years than in the past 6000 years

Mansoor Ahmed. MD, FACCP, FABSM

Medical Director, Cleveland Sleep & Research Center

Assistant Professor of Medicine

Case Western Reserve University

Fellow American Academy of Sleep Medicine

Overview Of Sleep Disorders Sleep Medicine……60 years of progress


History of Sleep Medicine…1953 to PresentFrom Basement To Congress to Wall Street Until 1975, Sleep Medicine was deemed experimental ,1995 Canada followed

4 Mile Stones : 1: REM Sleep 2: PSG 3 : Circadian Biology 4: OSA

    • 1964: Stanford Narcolepsy Center (C Dement Ad in SF Chronicle for Narcolepsy ..100

responded and 50 were diagnosed to have narcolepsy)

    • 1964 Association of Professional Sleep Societies (APSS)
  • 1968: R & K Manual of Sleep Scoring
  • 1970: Stanford Sleep Center
  • 1975: 5 Sleep Centers (Montefiore, OH State, Baylor, U-Pittsburg, and U-Cincinnati
  • 1975-1977: American Sleep Disorders Association, Accreditation
  • 1978: Certification Exam and Journal of SLEEP
  • 1990: US Congress Created National Commission on Sleep Disorders
  • 1991: ICSD-1 , ICSD 2: 2005
  • 1996 – At last…The AMA recognized sleep medicine as a specialty

European Development: First Sleep Text Book, Human EEG, Sleep Apnea.

  • 1963: Paris Symposium: ( Prof Fischgold) Sleep Epilepsy, Sleep Walking, Night Terrors.
  • 1965: Discovery Of Sleep Apnea by Gestualt ,Tassinar and Jung & Khulo
sleep a vital sign of human health bi directional relationship
Sleep……. A Vital Sign of Human Health: Bi-Directional relationship

Diabetes, Weight Gain, Hypothyroid

Insomnia and Hypersomnolence

PTSD, Anxiety

Mood Disorders, ADHD

OSA and …..

Hypertension, A Fib

MI, Stroke, CHF



Opioids & CSA

Pain Threshold

CFM –Pain & Sleep

Alzheimer's Disease, Stroke

Parkinson Disease

presentation summary
Presentation Summary

General Introduction

  • Normal sleep and why we sleep
  • Magnitude of Sleep Disorders , Sleep Deprivation and Public Health
  • Relationship between sleep and other medical specialties:

Sleep Disorders : Case Presentation: PTSD

  • Snoring & Obstructive Sleep Apnea
  • Circadian Rhythm Sleep Problems: Shift Work, Night Owl
  • Syndrome,: ADD-ADHD, Jet Lag Insomnia Narcolepsy and other Hypersomnolence Disorders
  • Restless Leg Syndrome
normal sleep
Normal Sleep

Put your thoughts to sleep,do not let them cast a shadowover the moon of your heart. Let go of thinking.


Sleep is essential for physical, emotional and mental health

functions of sleep
Functions of Sleep
  • We learned more about sleep functions when we don’t sleep
  • Emotional Integration, Memory Consolidation & REM sleep
  • Link between REM sleep and PTSD and other psychiatric disorders ……………..From Sigmund Freud to current status


  • Glial channels carrying CSF expand by 60% during sleep
  • Clean-up of any unwanted substances/ by products 2X more efficient
  • Implications in Alzheimer’s disease, stroke and dementia
  • Shift-workers pre-disposition to neurological disorders
medication and sleep
Medication and Sleep
  • Hypnotics and sedatives (benzo and non-benzo
  • OCD insomnia medications
  • Stimulants: Caffeine, Ritalin, Modafinil)
  • Adverse effects of commonly used medicine on sleep & Breathing :
  • Opioids: Center Sleep Apnea, Respiratory arrest
  • beta blockers: Melatonin and Insomnia
  • Alcohol: Most commonly used hypnotic , adverse effect on sleep
  • Caffeine: The most commonly used stimulant, effect on sleep and alertness.
















Normal Sleep

  • Rapid eye movement (REM) sleep
    • 20% to 25% of total sleep time
    • Active mind and Motor Paralysis
    • Intellectual Function
    • Sexual Functionality
  • Non–rapid eye movement (NREM)
    • Stage I Transition to sleep5% of
    • total sleep
    • Stage 2 50% of total sleep time
    • Stages 3 and 4 Slow-wave sleep
    • 10% to 20% of total sleep time
    • Growth Hormone
    • Age and delta sleep

Historical Perspective

Greeks: Hypnos &Thanatos

1929: Human EEG Alpha Waves (Hansberger)

1953: REM Sleep (Asrenski, Klietman and Dement)

1968: Sleep Stages Scoring Rules ( R&K)

1965: OSA Clinical Studies (Gastaut)

1970: Stanford First Sleep Clinic ( Dement)

1982: CPAP (John Remmer ,Sullivan)

magnitude of the sleep disorders
Magnitude of the Sleep Disorders

Underserved & Under-recognized Discipline

50-60 million American suffer from 80 identified sleep disorders

Sleep and Cardio-Vascular Disorders

51% of CHF patients has underlying sleep-breathing disorder

OSA is an independent risk factor for hypertension.

30-40% patients with hypertension has OSA

Mood Disorders and Sleep, PTSD, ADHD

70% of Patients with mood disorders has sleep pathology

Neurological Conditions

Sleep disturbance& fatigue are hallmark of MS, Parkinson disease, Alzheimer's Disease, Narcolepsy, Sleep Waking Disorders

Sleep Deprivation

Challenger Tragedy, >100,000 road accidents annually

Circadian Rhythm

Shift Work, Delayed Phase Syndrome

sleep public health challenges sleep deprivation shift work under diagnosis of sleep disorders

Sleep Public Health Challenges : Sleep Deprivation, Shift Work, Under Diagnosis of Sleep Disorders :


Federal Crash Statistics

The National Highway Traffic Safety Administration estimates

  • 100,000 police-report crashes annually
  • 1,550 fatalities (4%)
  • 71,000 injuries
  • $12.5 billion in monetary losses (Knipling 1995)
  • Another 1 million crashes are linked to inattention, which increases with fatigue (Wang 1996)
sleep disorders
Sleep Disorders

Case Presentation:

A: Snoring & Obstructive Sleep Apnea

B: Circadian Rhythm Sleep Problems: Shift Work, Night Owl Syndrome Jet Lag

C: Insomnia

D: Narcolepsy and other Hypersomnolence Disorders

E: Restless Leg Syndrome

What we are dealing with here, are two gigantic problems for our society – An epidemic of undiagnosed and untreated sleep disorders; and pervasive sleep deprivation with all its consequences for errors, accidents, disability, damages and death“

sleep disorders its not all about sleep apnea

Sleep and Psychiatry are inherently linked together at every level.. From disease mechanism to clinical Symptoms to outcomes Multiple Psychiatric Pathologies with Multiple Sleep Pathologies

47 Year female, history of depression, anxiety, history noted for childhood trauma, subsequent spousal abuse, alcohol abuse; History of Chronic Fibromyalgia referred by pain specialist for snoring and OSA evaluation :

History of Sleep initiation and Sleep Maintenance Insomnia, uncomfortable sensation in legs, night mares, teetth Clenching frequent nocturnal awakening, non-restorative sleep.,

Wake up tired, severe day-time sleepiness, cataplexy-sleep paralysis

Clinical Evaluations: Sleep Wakefulness history, ENT, PTSD scales

Investigations: Sleep Diary, PSG-MSLT

Sleep Diagnosis:

OSA, Restless Legs Syndrome, Chronic Insomnia

Bruxism, Narcolepsy:

Sleep Disorders………Its Not all about sleep apnea

rapid eye movement sleep
Rapid Eye Movement Sleep

Increased REM frequency

bruxism teeth clenching
Bruxism (Teeth Clenching)




Prevalence of Sleep ApneaNo sound epidemiological survey in general population using true random sample and had PSG
  • Wisconsin: Survey 3513-- 625 Accepted with 25% non snorersparticipants, age 30-60 underwent overnight PSG;
  • OSAS definition: AHI>5 with hyper somnolence
  • Ages 50-60 with RDI >15: 4% Women, 9.1% men
  • Peak Prevalence: 4.7%, Age: 45-64
  • Neck Size is more correlated to severity of apnea than BMI
  • 10% increase//Decrease in weight: 32% increase in AHI, 24% decrease
  • Age: SHHS: 20% Men, 10% women develop SA in 5 years,
  • 48% CHF patients have sleep Apnea,
  • Sleep Apnea incidence is far higher in patients with resistant hypertension, A -Fib, Diabetes

T Young, NEJM 1993; 328:1230-5

sleep disordered breathing disease mechanism

Narrow oropharynx but similar narrowing seen in normal Mechanism different in different patients due to factors related to control of breathingOSA worsens over the time Upper Airway Anatomy Plus Control of Breathing

Anatomy: Bony Structure, Soft Tissue, Obesity

Control of Breathing : Chemo responsiveness, Negative pressure

Upper Airway Muscles: Tongue, Palate, Hyoid Bone

Control Of Breathing : Magdy Younes, John Remmer, Jerry Dempsey, SafwanBadr, Neil Cherniack,

AtulMalhotra, David White , S Javaheri

Sleep Disordered BreathingDisease Mechanism




Thoracic effort





Airway obstructs

Airway opens

Effort gradually increases



Paradoxing Ends

Night Symptoms: Loud Snoring, Choking, Frequent awakening, Restless Sleep

Daytime tiredness/Sleepiness, Mood-Memory, Concentration

Consequences: Increased BP, Stroke, Diabetes,


Sleep-Disordered Breathing…. Disease Mechanism

Mechanism of Sleep-Apnea and Sleep Hpoventilation

1) Narrow Upper Airway: Obesity, E.N.T problems, Dysmorphism

2) Control of Breathing: Hormones, Cardiac Dysfunction

Apnea Hypopnea Hypoventilation

PO2 PCO2 Negative Intra-Thoracic Pressure

Arousal, Sympathetic Activation , Systemic-Pulmonary Vasoconst

Signs & Symptoms: Sleepiness, Hypertension- LV dysfunction ,


stop bang a simple screening tool for sleep apnea
STOP-BANGA simple screening tool for Sleep Apnea


  • Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?


  • Do you often feel tired, fatigued, or sleepy during daytime?


  • Has anyone observed you stop breathing during your sleep?


  • Do you have or are you being treated for high blood pressure?


  • BMI more than 35 kg/m2


  • Age over 50 yr old?

Neck circumference

  • Neck circumference greater than 40 cm , 15.7 inches?


  • Gender male?

High Risk

STOP: Yes to 2 or More

STOP BANG: Yes to 3 or more

epworth sleepiness scale ess
Epworth Sleepiness Scale (ESS)

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation

0 = would never dose; 1 = slight chance of dozing2 = moderate chance of dozing; 3 = high chance of dozing

SituationChance of Dozing (0-3)

Sitting and readingWatching TVSitting, inactive in a public place (eg, a theater or a meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic

Mitler and Miller. Behav Med. 1996;21:171.

consequences of osa longitudinal findings sleep health heart study 6441 patients
Consequences of OSALongitudinal Findings- Sleep Health Heart Study6441 Patients
  • Direct Cardiovascular Outcomes between 5 and 8.7 years
    • Hyperextension, Stroke, CHF .
    • Increased risk of Hypertension if higher BMI in men
    • With cardiovascular disease larger increases in AHI
  • Long Term Outcomes
    • Positive association between severity of SDB at PSG 1 and subsequent increase in BMI
    • Men more likely to have an increase in RDI with increase in weight than women
    • Both men and women had a greater increase in RDI with weight gain than a decrease in RDI with weight loss
    • Severe SDB showed increased risk of all-cause mortality in the 8.7 years following PSG
evaluation diagnosis
Evaluation & Diagnosis
  • Clinical Questions and Epworth
  • Home Sleep Study
  • PSG
types of sleep studies home sleep testing hst
Types of Sleep StudiesHome Sleep Testing ( HST)

Type 1 – Attended in-lab polysomnography

Type 2 – Comprehensive portable polysomnography

– Minimum of 7 channels including EEG, EOG, chin EMG, ECG/HR, airflow, respiratory effort and O2 saturation


Type 3 – Modified portable sleep apnea testing

– Minimum of 4 channels including ECG/HR, O2 saturation and at least 2 channels of respiratory movement or respiratory movement and airflow

Type 4 – Continuous single or dual bioparameters – For example, airflow and/or O2 saturation

emergent osa therapy
Emergent OSA Therapy
  • Weight Loss
  • CPAP
  • New PAP Modalities
  • Correction of enlarged tonsils, Sinuses, UA surgery
  • Oral Advancement Therapy
  • Implantable Neuro-stimulator
  • Provent: PEEP Mechanisms

CPAP is the most effective but compliance is the key issue

circadian sleep disorders
Circadian Sleep Disorders
  • Wake
    • During the day, SCN activity promotes arousal
    • Maintains state of wakefulness
  • Sleep
    • At night, SCN arousal is attenuated
    • Allows normal sleep to occur

SCN plays a pivotal role in maintaining wakefulness by generating an “alerting signal” that opposes the homeostatic sleep drive.

During the evening, the alerting signal is thought to be attenuated, in part via elevation in melatonin concentration during the night, allowing sleep to occur

sleep homeostasis and models of sleep regulation
Sleep Homeostasis and Models of Sleep Regulation

Borbély, A., & Achermann, P. (1999). Sleep Homeostasis and Models of Sleep Regulation Journal of Biological Rhythms, 14 (6), 559-570 DOI:

circadian rhythm sleep disorders crsd
Circadian Rhythm Sleep Disorders (CRSD)
  • “The essential feature of CRSDs is a persistent or recurrent pattern of sleep disturbance due primarily to alterations in the circadian timekeeping system or a misalignment between the endogenous circadian rhythm and exogenous factors that affect the timing or duration of sleep.” – ICSD-2.

6 Distinct CRSDs are recognized in the ICSD-2:

  • Delayed Sleep Phase Type (DSPD)
  • Advanced Sleep Phase Type (ASPD)
  • Irregular Sleep-Wake Phase Type (ISWR)
  • Free-Running Type (FRD)
  • Jet Lag Type (JLD)
  • Shift Work Type (SWD)
treatment crsd
Treatment- CRSD
  • Planned napping
  • Timed light exposure
  • Administration of melatonin
  • Enhance Alertness
  • Hypnotic medications
  • Insomnia is common and can have serious consequences, such as increased risk of depression and hypertension
  • Acute and chronic insomnia require different management approaches
  • Chronic insomnia is unlikely to spontaneously remit, and over time will be characterized by cycles of relapse and remission or persistent symptoms
  • Chronic insomnia is best managed using non-drug strategies and adjunctive use of medications

A symptom of either difficulty in falling asleep maintaining sleep or just sense of having insufficientsleep, causing an uncomfortable subjective experience, in some ways analogous to chronic pain

30% general population experience insomnia

Most of the patients patients with mood disorders has sleep pathology

Psychiatric disorders are the single largest cause of chronic insomnia in sleep-clinic population

prevalence of insomnia in the general adult population
Prevalence of Insomnia* in the General Adult Population








  • *Insomnia = sleep disturbance every night for two weeks or more, or similarly stringent criteria.
  • Ford DE, Kamerow DB. JAMA. 1989;262:1479-1484.
  • Ohayon MM, et al. Compr Psychiatry. 1998;39:185-197.
  • Ohayon MM, Roth T. J Psychosom Res. 2001;51:745-755.
  • Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S353.
  • Ishigooka J, et al. Psychiatry Clin Neurosci. 1999;53:515-522.
  • Simon GE, VonKorff M. Am J Psychiatry. 1997;154:1417-1423.
insomnia in patients with chronic medical conditions
Insomnia in Patients WithChronic Medical Conditions




Percentage of Patients

With Insomnia








*Sleep disturbance “some” or “a good bit” of the time for four weeks.

†Sleep disturbance “most” or “all” of the time for four weeks.

MI = myocardial infarction; CHF = congestive heart failure; BPH = benign prostatic hypertrophy.

Katz DA, McHorney CA. Arch Intern Med. 1998;158:1099-1107.

insomnia treatment
Insomnia Treatment
  • Sleep Hygiene
  • Cognitive Behavior Therapy
  • Pharmacotherapy
therapeutic agents
Therapeutic Agents
  • Sedative-hypnotics
  • Sedating antidepressants
  • Selective melatonin agonist and Melatonin
  • Antihistamines
  • Anxiolytics
  • Alternative and herbal medications- Valerian Root Extract

Hypnotics can be used on long term basis in Primary Insomnia

Exercise, CBT, Sleep Hygiene

components of cognitive behavior therapy
Components of Cognitive Behavior Therapy
  • Stimulus control (daytime and sleeping environments)
  • Sleep restriction
  • Relaxation techniques (progressive relaxation, imagery training, biofeedback, meditation, hypnosis and autogenic training) to reduce physical and mental arousal
  • Reduce negative perceptions about battle ground of sleep
  • Write about worries in the evening
  • Stopping thoughts (repeating word “the” every three sec.)
  • Sleep hygiene education
what to do and not to do
What to do and not to Do
  • Recognize that there is a sleep problem & bring it to the attention
  • What is the nature of Sleep Problem:

Insomnia, Sleep Apnea, Restless Legs, Shift Work

3. Determine Circadian Phase

Diet/light snack , exercise, hot bath, relaxing techniques, Bed timing and sleep timing, prescription medications

What Not to do

Clock watching, thinking about next day issues, worrying about sleep, Coffee/Smoking/Alcohol Catching-up over the week-ends

mechanistic approach


  • Idiopathic Hypersomnia
  • Post-Traumatic Hypersomnia
  • Mood Disorders
  • Sleep Apnea
  • PLMS/Leg Movements
  • Sleep Walking

Mechanistic Approach

Sleep-Wake Dysregulation

Sleep Disruption

Circadian Misalignment

Excessive Sleepiness Disorders

  • Delayed Phase Syndrome
  • Advanced Phase Syndrome
  • Shift Work Disorder
  • Non-24 hour Rhythm


  • Characterized by excessive sleepiness + cataplexy and other REM phenomena
    • Sleep paralysis
    • Hypnagogic hallucinations
  • Etiology unknown
  • Pathology:
  • Genetic predisposition
  • Hypocretin/orexin deficiency
  • Autoimmune disease
  • Neurochemical abnormalities
  • Environmental triggers
  • Head trauma

Assessment of Sleepiness


  • Facial expression, posture, yawning, myosis


  • Epworth Sleepiness Scale (ESS)
  • Stanford Sleepiness Scale (SSS)


  • Multiple Sleep Latency Test (MSLT)
  • Polysomnography (PSG)
  • Actigraphy
  • Maintenance of Wakefulness Test (MWT)

Mitler and Miller. Behav Med. 1996;21:171.


Sleepiness and REM Sleep Assessed by Multiple Sleep Latency Test (MSLT)

Number of REM Periods

Recorded in All 5 Naps

Sleep Latency






13.4 ± 4



REM periods/5 naps








3.0 ± 2.7












Control N=17Narcolepsy N=57

Adapted from Mitler et al. Psychiatr Clin North Am. 1987;10:593.


Narcolepsy: Traditional Management Approaches

Excessive daytime sleepiness

  • Structured nocturnal sleep
  • Naps: scheduled and PRN
  • Stimulants or wake promoting agents


  • Antidepressants (TCA or SSRI)

Sleep fragmentation

  • Sleep hygiene
  • Hypnotics (limited utility)


  • Personal and family counseling
  • Support

Parkes. Sleep. 1994;17:S93; Mitler M et al. Sleep. 1994;17:352;

Daly and Yoss. Narcolepsy. In: Handbook of clinical Neurology. Vol.15.1994;15:836; Bassetti and Aldrich. Neurol Clin. 1996;14:545; Mamelak et al. Sleep. 1986;9:285.

restless legs syndrome
Restless Legs Syndrome

Key RLS Diagnostic Criteria

  • Urge to move legs-usually accompanied by uncomfortable sensations
  • Temporary relief with movement
  • Onset or worsening of symptoms at rest or inactivity, such as lying or sitting
  • Worsening of symptoms in the evening or at night

Other Diagnostic Considerations

  • Positive family history of Restless Legs Syndrome
  • Periodic limb movements during wakefulness or sleep (PLMW or PLMS)
  • Sleep disturbance
types of rls
Types of RLS

Primary RLS

  • Genetic or Familial

Secondary RLS

  • Iron deficiency
  • Pregnancy
  • End-stage renal disease
  • Various polyneuropathies
treatment what to expect
Treatment: What to Expect
  • Treatment of underlying causes of RLS
  • Several prescription medications very effective
  • Effectiveness of medication varies for each person
  • Worsening of symptoms
key messages
Key Messages
  • Sleep is critical for physical and mental health, and emotional restoration
  • Sleep loss / inadequate or disturbed sleep compromises all treatments and therapies
  • Sleep Function: Emotional Integration, Memory Consolidation, Clean-up of unwanted substances in the brain
  • 50-60 million Americans suffer from chronic sleep disorders, with most common ones being: chronic insomnia; obstructive sleep apnea; restless legs syndrome, and disorders of severe sleepiness including shift work syndrome and narcolepsy
  • despite the fact that sleep disorders are not difficult to diagnose, a majority of sleep disorder sufferers remain undiagnosed
  • A greater need for implementing screening tools: STOP-BANG for sleep apnea; Epworth Sleepiness Scale for excessive sleepiness
  • Sleep and Sleep disturbances play a central role in the mechanism of psychiatric disorders such as PTSD, depression and anxiety. Evaluation of sleep and correction of disturbed sleep should be CRTICAL part of any treatment
  • Sleep disorders are predictive of Parkinson's and Alzheimer's disease
  • Sleep disorders can be effectively managed and treated, with significant improvement in quality of life
  • Importance of Public Health Awareness…….Sleep Education
  • Parents
  • Mentors: Magdy Younes, J Remmers, Nick Anthonison, M Kryger
  • Patients
  • Colleagues: RozinaAamir, Zahra Jishi, Martin Scharf
  • Maryam Ahmed , AbdulrazzakDardari
  • Staff, Alithea, Sandy, Noel Cyrill, Nancy, Eden

Nazima and Shazeena